It is well recognised that care for community-dwelling older people needs improvement.1,2 Current health and social services are particularly insufficient for frail older people who suffer from multiple health and social problems.3,4 Care should change from being reactive and disease oriented to proactive and patient oriented; this is often called integrated care.5,6 First, though, the older people who would benefit from integrated care, that is those who are frail, must be identified.7
Many instruments for the identification of frailty can be found in the literature. Some, such as the Fried frailty criteria, focus on frailty as a physical syndrome,8,9 whereas others use a ‘broader’ definition in which psychological and social aspects are incorporated, such as the Frailty Index by Rockwood and the Tilburg Frailty Indicator (TFI).10–12 This ‘broader’ definition is more consistent with the way the term frailty is used by clinicians in primary care.12 However, most of these instruments are not specifically validated for use in primary care. Furthermore, the existing instruments have other limitations that make them less suitable for use in primary care. First, the available instruments neglect information about patients that is already available, such as prior knowledge of the professionals involved. Yet, it is probably more efficient to make use of the existing infrastructure of primary care, and to profit from the information that GPs and their teams already have of individual patients. In addition, the existing frailty instruments use cut-off scores and neglect tacit knowledge. In clinical decision making, most GPs rely not only on explicit factual knowledge, but also on tacit (implicit) knowledge.13 Hence, using the professionals’ appraisal in a frailty instrument, in addition to a standardised frailty instrument, might have added value.
A final limitation of the existing instruments is that most of them do not take into account the care context of the patient. As the requirement is to identify frail older people in need of integrated care, it is important to consider this context, since it is strongly related to the frailty status of a patient.14 The significance of considering the care context in relation to frailty is that it focuses on relevant contextual factors that may require more integration of the care system.
Taking into account the above-mentioned limitations of existing frailty instruments, this study developed a new frailty-identification instrument with the input of stakeholders from primary care. This instrument was based on the EASY-Care assessment system,15 which is a tool for geriatric assessment in primary care and is a good starting point for integrated care. This article describes the development process of the Easycare Two-step Older persons Screening (Easycare-TOS), and answers the question as to whether it is possible to develop an efficient, flexible, and acceptable method for the identification of community-dwelling frail older people as a target population for integrated care.
How this fits in
In the literature, many instruments for the identification of frailty can be found. However, these instruments have scarcely been validated for use in primary care. Therefore, the Easycare Two-step Older persons Screening (Easycare-TOS) was developed. Distinctive characteristics of the Easycare-TOS are that it makes optimal use of prior knowledge of the GP and that, instead of a cut-off score, the professionals’ appraisal is decisive in the judgement of frailty.
